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Dialysis and Replacement Solutions for Pediatric CRRT

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Description of solutions currently available for CRRT. Considerations in choosing a solution for CRRT ... Bicarbonate has superseded lactate ... – PowerPoint PPT presentation

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Title: Dialysis and Replacement Solutions for Pediatric CRRT


1
Dialysis and Replacement Solutions for Pediatric
CRRT
  • Jordan M. Symons, MD
  • University of Washington School of Medicine
  • Childrens Hospital Regional Medical Center
  • Seattle, WA
  • jordan.symons_at_seattlechildrens.org

2
CRRT SolutionsOutline of the Talk
  • Purpose of solutions in CRRT
  • Goals for a CRRT solution
  • Description of solutions currently available for
    CRRT
  • Considerations in choosing a solution for CRRT

3
First CAVH Circuit
Kramer, P, et al. Arteriovenous haemofiltration
A new and simple method for treatment of
over-hydrated patients resistant to diuretics.
Klin Wochenschr 551121-2, 1977.
4
CAVH Good for Fluid Balance,Not So Good for
Metabolic Balance
  • CAVH removes all molecules slowly
  • Good for BP stability (slow UF)
  • Not so good for metabolic control
  • Need method to increase molecular clearance
    without increasing UF rate

5
  • Diffusion
  • Small molecules diffuse easily
  • Larger molecules diffuse slowly
  • Dialysate required
  • Concentration gradient
  • Faster dialysate flow increases mass transfer

6
  • Convection
  • Small/large molecules move equally
  • Limit is cut-off size of membrane
  • Higher UF rate yields higher convection but risk
    of hypotension
  • May need to Replace excess UF volume

Neg Press
H2O
H2O
H2O
H2O
7
Solutions in CRRT Address Molecular Control Issues
  • Improved mass transfer using diffusion,
    high-grade convection, or combination
  • CVVH a pure convection modality
  • CVVHD a diffusion modality
  • CVVHDF combined convection/diffusion
  • Permits correction of metabolic abnormalities
  • Provides complete renal replacement

8
Characteristics of the Ideal CRRT Solution
  • Physiological
  • Reliable
  • Inexpensive
  • Easy to prepare
  • Simple to store
  • Quick to the bedside
  • Widely available
  • Fully compatible

9
Options for CRRT Solutions
  • Peritoneal dialysate
  • Pre-made IV solutions
  • Saline, Lactated Ringers
  • Multi-bag systems
  • Custom-made solutions
  • Local pharmacy outsource
  • Commercially available CRRT solutions

NO
MAYBE
UNNECESSARY
RARELY
10
Commercial Solutions for CRRT Several Companies,
Multiple Options
  • Previously limited options
  • No bicarbonate-based solutions
  • US regulations re drug vs. device
  • Currently multiple manufacturers each offering a
    variety of formulations
  • Bicarbonate as primary or only base
  • The Choice may depend on local policy, vendors,
    economic pressures

11
Normocarb (DSI)
  • Bicarbonate buffered
  • Concentrate must be compounded
  • Final volume 3.24 liters (240ml concentrate added
    to 3 L bag)

12
Chemical Content of Normocarb
13
Normocarb HF (DSI)
  • Bicarbonate buffered
  • Concentrate must be compounded
  • Final volume 3.24 liters (240ml concentrate added
    to 3 L bag)
  • 2 ionic formulations
  • Normocarb HF 25
  • Normocarb HF 35

14
Chemical Content of Normocarb HF
15
PrismaSate (Gambro)
  • Bicarbonate buffered
  • Small amount of lactate
  • 5 liter bag
  • 2 compartments to prevent precipitation
  • Six ionic formulations

16
Chemical Content of PrismaSate
17
PrismaSol (Gambro)
  • Bicarbonate buffered
  • Small amount of lactate
  • 5 liter bag
  • 2 compartments to prevent precipitation
  • Seven ionic formulations

18
Chemical Content of PrismaSol
19
Accusol (Baxter)
  • Bicarbonate buffered
  • No lactate
  • 2.5 liter bag
  • 2 compartments to prevent precipitation
  • Five ionic formulations

20
Chemical Content of Accusol
21
Duosol (B.Braun)
  • Bicarbonate buffered
  • No lactate
  • 5 liter bag
  • 2 compartments to prevent precipitation
  • Three ionic formulations

22
Chemical Content of Duosol
23
NxStage PureFlow (NxStage)
  • Part of NxStage System One for acute care
  • 5 liter bags
  • Choice of buffers
  • Lactate 3 formulations single-chamber bag
  • Bicarbonate 5 formulations dual-chamber bag

24
Chemical Content of NxStage PureFlow (1)
25
Chemical Content of NxStage PureFlow (2)
26
Choosing a Solution Issues to Consider
  • Cost
  • Anticoagulation
  • Patient safety
  • CRRT modality
  • Diffusion (CVVHD)
  • Convection (CVVH)
  • Both (CVVHDF)

27
Anticoagulation and Solutions
May need to consider Ca content if using
citrate for anticoagulation
28
Evaluation of Errors in Preparation of CRRT
Solutions
  • Survey of 3 Pediatric Listserves
  • Pediatric Critical Care, Nephrology, CRRT
  • 16/31 programs reported solution compounding
    errors
  • Consequences of improper solutions
  • 2 deaths
  • 1 non lethal cardiac arrest
  • 6 seizures (hypo/hypernatremia)
  • 7 without complications

Barletta et al, Pediatr Nephrol. 21(6)842-5,
2006 Jun
29
FDA Approval Status of CRRT Solutions
30
Putting it All Together One Approach
  • CRRT with citrate regional anticoag
  • DIALYSATE commercial bicarb-based solution
  • REPLACEMENT normal saline
  • Adjust blend, change saline if indicated

31
On-Line Dialysate with SLED An Alternative to
Solutions in CRRT
  • Extended sessions using standard dialysis
    equipment
  • Dialysate made on-line from concentrates
  • Simple, convenient, MUCH cheaper
  • Dialysate is not sterile

32
Citrasate(Advanced Renal Technologies)
  • A concentrate for dialysis
  • Liquid or bulk powder
  • Citrate used as acidifying agent
  • Local anticoagulation greatly reduces need for
    heparin

33
CRRT Solutions Summary
  • Solutions needed to maximize clearance
  • Bicarbonate has superseded lactate
  • Industry-made solutions are available including
    some approved for replacement
  • Pre-mixed, sterile solutions for CRRT are simple,
    safe, may be costly
  • On-line dialysate for SLED is clean (not
    sterile), simple, cheap
  • The best solution may still be pending

34
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